What is a Developmental-Behavioral Pediatrician?

If your child has a developmental, learning, or behavioral problem, a developmental-behavioral pediatrician has the
training and expertise to evaluate and care for your child. Developmental-behavioral pediatricians possess training
and experience to consider, in their assessments and treatments, the medical and psychosocial aspects of children’s
and adolescents’ developmental and behavioral problems.

What training do developmental-behavioral pediatricians have?

Developmental-behavioral pediatricians are medical doctors who have completed

 Four years of medical school

 Three years of residency training in pediatrics
 Board certification in pediatrics
 Additional subspecialty training in developmental-behavioral pediatrics
In 2002, the American Board of Pediatrics began certifying developmental-behavioral pediatricians via a
comprehensive examination process.

Developmental-behavioral pediatricians evaluate, counsel, and provide treatment for

children, adolescents, and their families with a wide range of developmental and behavioral
difficulties, including
 Learning disorders including dyslexia, writing diffi culties, math disorders, and other school-
related learning problems
 Attention and behavioral disorders including attention-deficit/hyperactivity disorder and associated
conditions including oppositional-defiant behavior, conduct problems, depression, and anxiety
disorders
 Tics, Tourette syndrome, and other habit disorders
 Regulatory disorders including sleep disorders, feeding problems, discipline difficulties,
complicated toilet-training issues, enuresis (bedwetting), and encopresis (soiling)
 Developmental disabilities including cerebral palsy, spina bifi da, mental retardation, autism
spectrum disorders, and visual and hearing impairments
 Delayed development in speech, language, motor skills, and thinking ability
 Behavioral and developmental problems complicating the full range of pediatric chronic illnesses
and disabling conditions (for example, genetic disorders, epilepsy, prematurity, diabetes, asthma,
cancer)
Where can I find a developmental-behavioral pediatrician?
Developmental-behavioral pediatricians practice in hospitals, major medical centers, clinics, private practice settings,
rehabilitation centers, schools, and community centers.

Often a developmental-behavioral pediatrician works collaboratively with a team of professionals. This team may
include a psychologist, speech-language pathologist, occupational therapist, physical therapist, neurodevelopmental
disabilities pediatrician, child psychiatrist, child neurologist, nurse practitioner, physician’s assistant, educational
diagnostician, or clinical social worker.

Developmental-behavioral pediatricians work closely with parents, families, and schools.

Developmental-behavioral pediatricians understand that children’s development and behavior happen first and
foremost in the context of the family. They seek to understand the family’s view of the problem and the effect of the
child’s problem on the family. Developmental-behavioral pediatricians advocate for their patients with developmental
and behavioral problems by working closely with schools, preschools, and other agencies involved with
developmental care and education.
Conduct Disorder
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No. 33; Updated August 2013

Click here to download and print a PDF version of this document.
"Conduct disorder" refers to a group of behavioral and emotional problems in youngsters. Children and
adolescents with this disorder have great difficulty following rules and behaving in a socially acceptable
way. They are often viewed by other children, adults and social agencies as "bad" or delinquent, rather
than mentally ill. Many factors may contribute to a child developing conduct disorder, including brain
damage, child abuse or neglect, genetic vulnerability, school failure, and traumatic life experiences.
Children or adolescents with conduct disorder may exhibit some of the following behaviors:

Aggression to people and animals

 bullies, threatens or intimidates others
 often initiates physical fights
 has used a weapon that could cause serious physical harm to others (e.g. a bat, brick, broken
bottle, knife or gun)
 is physically cruel to people or animals
 steals from a victim while confronting them (e.g. assault)
 forces someone into sexual activity
Destruction of Property
 deliberately engaged in fire setting with the intention to cause damage
 deliberately destroys other's property
Deceitfulness, lying, or stealing
 has broken into someone else's building, house, or car
 lies to obtain goods, or favors or to avoid obligations
 steals items without confronting a victim (e.g. shoplifting, but without breaking and entering)
Serious violations of rules
 often stays out at night despite parental objections
 runs away from home
 often truant from school
Children who exhibit these behaviors should receive a comprehensive evaluation by an experience
mental health professional. Many children with a conduct disorder may have coexisting conditions such
as mood disorders, anxiety,PTSD, substance abuse, ADHD, learning problems, or thought disorders
which can also be treated. Research shows that youngsters with conduct disorder are likely to have
ongoing problems if they and their families do not receive early and comprehensive treatment. Without
treatment, many youngsters with conduct disorder are unable to adapt to the demands of adulthood and
continue to have problems with relationships and holding a job. They often break laws or behave in an
antisocial manner.
Treatment of children with conduct disorder can be complex and challenging. Treatment can be provided
in a variety of different settings depending on the severity of the behaviors. Adding to the challenge of
treatment are the child's uncooperative attitude, fear and distrust of adults. In developing a
comprehensive treatment plan, a child and adolescent psychiatrist may use information from the child,
family, teachers, community (including the legal system) and other medical specialties to understand the
causes of the disorder.
Behavior therapy and psychotherapy are usually necessary to help the child appropriately express and
control anger.Special education may be needed for youngsters with learning disabilities. Parents often
need expert assistance in devising and carrying out special management and educational programs in the
home and at school. Home-based treatment programs such as Multisystemic Therapy are effective for
helping both the child and family.Treatment may also include medication in some youngsters, such as
those with difficulty paying attention, impulse problems, or those with depression.
Treatment is rarely brief since establishing new attitudes and behavior patterns takes time. However,
early treatment offers a child a better chance for considerable improvement and hope for a more
successful future.

The Disobedient Child

What can be done about a chronically disobedient child?

From time to time most children defy the wishes of their parents. This is a part of growing up and testing adult
guidelines and expectations. It is one way for children to learn about and discover their own selves, express their
individuality, and achieve a sense of autonomy. As they stretch their independent wings and engage in minor conflicts
with their parents, they discover the boundaries of their parents' rules and of their own self-control.

Sometimes, however, these conflicts are more than occasional disturbances and become a pattern for how parents
and children interact. Disobedience can have a variety of causes. At times, it is due to unreasonable parental
expectations. Or it might be related to the child's temperament, or to school problems, family stress, or conflicts
between his parents.

What parents can do

 When you have a chronically disobedient child, examine the possible sources of his inner turmoil and rebelliousness.
If this has been a persistent pattern that has continued into middle childhood, closely evaluate your own family
situation:

 How much respect do your family members show for one another?
 Do they respect one another's privacy, ideas, and personal values?
 How does the family work out its conflicts?
 Are disagreements resolved through rational discussion, or do people regularly argue or resort to
violence?
 What is your usual style of relating to your child, and what forms does discipline usually take?
 How much spanking and yelling is there?
 Do you and your child have very different personalities and ways of getting along in the world that
cause friction between you?
 Is your child having trouble succeeding at school or developing friendships?
 Is the family undergoing some especially stressful times?
If your child has only recently started to demonstrate disrespect and disobedience, tell him that you have noticed a
difference in his behavior and that you sense he is unhappy or struggling. With his help, try to determine the specific
cause of his frustration or upset. This is the first step toward helping him change his behavior.

Your reaction matters

If you react to your child's talking back by exploding or losing your temper, he will respond with disobedience and
disrespect. By contrast, he will become more obedient when you remain calm, cooperative, and consistent. He will
learn to be respectful if you are respectful toward him and others in the family. If he becomes disobedient and out of
control, impose a timeout until he calms down and regains self-control.

When your child is obedient and respectful, compliment him for that behavior. Reward the behavior you are seeking,
including cooperation and resolution of disagreements. These positive efforts will always be much more successful
than punishment.

When to seek additional help

For some disobedient children, you may need to obtain professional mental health treatment. Here are some
situations where outside counseling may be necessary:

 If there is a persistent, long-standing pattern of disrespect of authority both at school and at

home.
 If the patterns of disobedience continue in spite of your best efforts to encourage your child to
communicate his negative feelings
 If a child's disobedience and/or disrespect is accompanied by aggressiveness and
destructiveness
 If a child shows signs of generalized unhappiness -- perhaps talking of feeling blue, unliked,
friendless, or even suicidal
 If your family has developed a pattern of responding to disagreements with physical or emotional
abuse
 If you or your spouse or child use alcohol or other drugs to feel better or cope with stress
If relationships within your family show signs of difficulty and lack of cooperation, then family therapy may be
indicated. By dealing with and resolving these problems at a young age, you can minimize and even prevent more
serious struggles that may emerge as your children reach adolescence. The key is early identification and treatment.
 Disruptive Behavior Disorders
Disruptive behavior disorders are among the easiest to identify of all coexisting conditions because they involve
behaviors that are readily seen such as temper tantrums, physical aggression such as attacking other children,
excessive argumentativeness, stealing, and other forms of defiance or resistance to authority. These disorders, which
include ODD and CD, often first attract notice when they interfere with school performance or family and peer
relationships, and frequently intensify over time.

Behaviors typical of disruptive behavior disorders can closely resemble ADHD—particularly where impulsivity and
hyperactivity are involved—but ADHD, ODD, and CD are considered separate conditions that can occur
independently. About one third of all children with ADHD have coexisting ODD, and up to one quarter have coexisting
CD. Children with both conditions tend to have more difficult lives than those with ADHD alone because their defiant
behavior leads to so many conflicts with adults and others with whom they interact. Early identification and treatment
may, however, increase the chances that your child can learn to control these behaviors.

Oppositional Defiant Disorder

Many children with ADHD display oppositional behaviors at times. Oppositional defiant disorder is defined in the
American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-
IV)  as including persistent symptoms of “negativistic, defiant, disobedient, and hostile behaviors toward authority
figures.” A child with ODD may argue frequently with adults; lose his temper easily; refuse to follow rules; blame
others for his own mistakes; deliberately annoy others; and otherwise behave in angry, resentful, and vindictive ways.
He is likely to encounter frequent social conflicts and disciplinary situations at school. In many cases, particularly
without early diagnosis and treatment, these symptoms worsen over time—sometimes becoming severe enough to
eventually lead to a diagnosis of conduct disorder.

Conduct Disorder
Conduct disorder is a more extreme condition than ODD. Defined in the DSM-IV as “a repetitive and persistent
pattern of behavior in which the basic rights of others or major age appropriate social rules are violated,” CD may
involve serious aggression toward people or the hurting of animals, deliberate destruction of property (vandalism),
stealing, running away from home, skipping school, or otherwise trying to break some of the major rules of society
without getting caught. Many children with CD were or could have been diagnosed with ODD at an earlier age—
particularly those who were physically aggressive when they were younger. As the CD symptoms become evident,
these children usually retain their ODD symptoms (argumentativeness, resistance, etc) as well. This cluster of
behaviors, combined with the impulsiveness and hyperactivity of ADHD, sometimes causes these children to be
viewed as delinquents, and they are likely to be suspended from school and have more police contact than children
with ADHD alone or ADHD with ODD. 

Children with ADHD whose CD symptoms started at an early age also tend to fare more poorly in adulthood than
those with ADHD alone or ADHD with ODD—particularly in the areas of delinquency, illegal behavior, and substance
abuse.

ODD and CD: What to Look For

A child with ADHD and a coexisting disruptive behavior disorder is likely to be similar to children with ADHD alone in
terms of intelligence, medical history, and neurological development. He is probably no more impulsive than children
with ADHD alone, although if he has conduct disorder, his teachers or other adults may misinterpret his aggressive
behavior as ADHD-type impulsiveness. (Attention-deficit/hyperactivity disorder behavior without CD, however, does
not typically involve this level of aggression.) A child with ADHD and CD does have a greater chance of experiencing
learning disabilities such as reading disorders and verbal impairment. But what distinguishes children with ODD and
CD most from children with ADHD alone is their defiant, resistant, even (in the case of CD) aggressive, cruel, or
delinquent, behavior. Other indicators to look for include

 Relatives with ADHD/ODD, ADHD/CD, depressive disorder or anxiety disorder. A child with
family members with ADHD/ODD or ADHD/CD should be watched for ADHD/CD as well. Chances of
developing CD are also greater if family members have experienced depressive, anxiety, or learning
disorders. 
 Stress or conflict in the family. Divorce, separation, substance abuse, parental criminal activity,
or serious conflicts within the family are quite common among children with ADHD and coexisting ODD
or CD. 
 Poor or no positive response to the behavior therapy techniques at home and at school. If
your child defies your instructions, violates time-out procedures, and otherwise refuses to cooperate
with your use of appropriate behavior therapy techniques, and his aggressive behavior continues
unabated, he should be evaluated for coexisting ODD or CD.
Treatment
Children with ADHD and disruptive behavior disorders often benefit from special behavioral techniques that can be
implemented at home and at school. These approaches typically include methods for training your child to become
more aware of his own anger cues, use these cues as signals to initiate various coping strategies (“Take five deep
breaths and think about the three best choices for how to respond before lashing out at a teacher.”), and provide
himself with positive reinforcement (telling himself, “Good job, you caught the signal and used your strategies!”) for
successful self-control. You and your child’s teachers, meanwhile, can learn to better manage ODD or CD-type
behavior through negotiating, compromising, problem-solving with your child, anticipating and avoiding potentially
explosive situations, and prioritizing goals so that less important problems are ignored until more pressing issues
have been successfully addressed. These highly specific techniques can be taught by professional behavior
therapists or other mental health professionals recommended by your child’s pediatrician or school psychologist, or
other professionals involved with your family.

If your child has a diagnosis of coexisting ODD or CD, and well-planned classroom behavioral techniques in his
mainstream classroom have been ineffective, this may lead to a decision to place him in a special classroom at
school that is set up for more intensive behavior management. However, schools are mandated to educate your child
in a mainstream classroom if possible, and to regularly review your child’s education plan and reassess the
appropriateness of his placement.

There is growing evidence that the same stimulant medications that improve the core ADHD symptoms may also help
coexisting ODD and CD. Stimulants have been shown to help decrease verbal and physical aggression, negative
peer interactions, stealing, and vandalism. Although stimulant medications do not teach children new skills, such as
helping them identify and respond appropriately to others’ social signals, they may decrease the aggression that
stands in the way of forming relationships with others their age. For this reason, stimulants are usually the first choice
in a medication treatment approach for children with ADHD and a coexisting disruptive behavior disorder.

The earlier stimulants are introduced to treat coexisting ODD or CD, the better. A child with a disruptive behavior
disorder whose aggressive behavior continues untreated may start to identify with others who experience discipline
problems. By adolescence, he may resist treatment that could help him change his behavior and make him less
popular among these friends. He will have grown accustomed to his defiant “self” and feel uncomfortable and “unreal”
when stimulants help check his reckless, authority-flaunting style. By treating these behaviors in elementary school or
even earlier, you may have a better chance of preventing your child from creating a negative self-identity.

If your child has been treated with 2 or more types of stimulants and his aggressive symptoms are the same or
worse, his pediatrician may choose to reevaluate the situation and replace the stimulant with other medications. If
stimulant medication alone led to some but not enough improvement, his pediatrician may continue to prescribe
stimulants in combination with one of these other agents.

Fighting And Biting

All people have aggressive feelings. As adults, we learn how to control these feelings. Children, however,
are often physically aggressive B they hit, bite and scratch others. These behaviors are fairly common
and often appear by the child's first birthday. Parents often struggle over how to manage their child's
aggressive and/or destructive behavior.

While some biting can occur during normal development, persistent biting can be a sign that a child has
emotional or behavioral problems. While many children occasionally fight with or hit others, frequent
and/or severe physical aggression may mean that a child is having serious emotional or behavioral
problems that require professional evaluation and intervention. Persistent fighting or biting when a child is
in daycare or preschool can be a serious problem. At this age, children have much more contact with
peers and are expected to be able to make friends and get along.

Biting
Many children start aggressive biting between one and three years of age. Biting can be a way for a child
to test his or her power or to get attention. Some children bite because they are unhappy, anxious or
jealous. Sometimes biting may result from excessive or harsh discipline or exposure to physical violence.
Parents should remember that children who are teething might also bite. Biting is the most common
reason children get expelled from day care.

What to do:
 Say "no", immediately, in a calm but firm and disapproving tone.
 For a toddler (1-2 years), firmly hold the child, or put the child down.
 For a young child (2-3 years) say, "biting is not okay because it hurts people."
 Do NOT bite a child to show how biting feels. This teaches the child aggressive behavior.
 If biting persists, try a negative consequence. For example, do not hold or play with a child for
five minutes after he or she bites.
If these techniques or interventions are not effective, parents should talk to their pediatrician or family
physician.
Fighting and Hitting
Toddlers and preschool age children often fight over toys. Sometimes children are unintentionally
rewarded for aggressive behavior. For example, one child may push another child down and take away a
toy. If the child cries and walks away, the aggressive child feels successful since he or she got the toy. It
is important to identify whether this pattern is occurring in children who are aggressive.

What to do:
 It is more effective to intervene before a child starts hitting. For example, intervene as soon as
you see the child is very frustrated or getting upset.
 When young children fight a lot, supervise them more closely.
 If a child hits another child, immediately separate the children. Then try to comfort and attend
to the other child.
 For a toddler (1-2 years) say, "No hitting. Hitting hurts."
 For a young child (2-3 years) say, "I know you are angry, but don't hit. Hitting hurts." This
begins to teach empathy to your child.
 Do NOT hit a child if he or she is hitting others. This teaches the child to use aggressive
behavior.
 Parents should not ignore or down play fighting between siblings.
When hitting or fighting is frequent, it may be a sign that a child has other problems. For example, he or
she may be sad or upset, have problems controlling anger, have witnessed violence or may have been
the victim of abuse at day care, school, or home.

Research has shown that children who are physically aggressive at a younger age are more likely to
continue this behavior when they are older. Studies have also shown that children who are repeatedly
exposed to violence and aggression from TV, videos and movies act more aggressively. If a young child
has a persistent problem with fighting, biting or aggressive behavior, parents should seek professional
assistance from a child and adolescent psychiatrist or other mental health professional who specializes in
the evaluation and treatment of behavior problems in very young children.
‘

What Should I Do?

When a child has been caught stealing, a parent's reaction should depend on whether it's the first time
or there's a pattern of stealing.

With very young children, parents need to help them understand that stealing is wrong — that when
you take something without asking or paying for it, it hurts someone else. If a preschooler takes a
piece of candy, for instance, parents can help the child return the item. If the child has already eaten
the candy, parents can take the child back to the store to apologize and pay for it.

With school-age kids, too, it's important to return the stolen item. By the first and second grades, kids
should know stealing is wrong. But they may need a better understanding of the consequences.

Here's an example: If a child comes home with a friend's bracelet and it's clear the child took it
without the friend's permission, the parent should talk to the child about how it would feel if a friend
took something without asking first. The parent should encourage the child to call the friend to
apologize, explain what happened, and promise to return it.

When teens steal, it's recommended that parents follow through with stricter consequences. For
example, when a teen is caught stealing, the parent can take the teen back to the store and meet with
the security department to explain and apologize for what happened. The embarrassment of facing up
to what he or she did by having to return a stolen item makes for an everlasting lesson on why
stealing is wrong.

Further punishment, particularly physical punishment, is unnecessary and could make the child angry
and more likely to engage in even worse behavior.

If it's a first-time offense, some stores and businesses may accept an apology and not necessarily
press charges. However, some stores press charges the first time around. And there's often little
sympathy for repeat offenders.

Kids of all ages need to know that shoplifting isn't just about taking things from a store — it's taking
money from the people who run the businesses. Plus, shoplifting makes prices higher for other
customers. They should also know that stealing is a crime and can lead to consequences far worse
than being grounded, including juvenile detention centers and even prison.

If stealing money from a parent, the child should be offered options for paying back the money, like
doing extra chores around the house. It's important, however, that a parent not bait the child by
leaving out money in the hopes of catching the child in the act. That could damage the sense of trust
between a parent and child.

If a Child Keeps Stealing

If your child has stolen on more than one occasion, consider getting professional help. Repeat offenses
may indicate a bigger problem.

One third of juveniles who've been caught shoplifting say it's difficult for them to quit. So, it's
important to help kids and teens understand why stealing is wrong and that they may face serious
consequences if they continue to steal.

Others who may be able to talk to you and/or your child about the problem and help you address it
include a:

 family therapist or counselor

 family doctor (who may be able to refer you to a family therapist or counselor)
 minister, priest, or rabbi
 school counselor (especially if your child is stealing from the school)
 support group, such as the National Association for Shoplifting Prevention (NASP) or
Cleptomaniacs and Shoplifters Anonymous (CASA), which may be able to provide information or
help (look in your phone book for groups in your area)

Although most ordinary acts of theft or shoplifting are deliberate, some people who steal may have
kleptomania. With this rare compulsive disorder, which makes up a very small portion of all shoplifting
cases, a person feels a sense of tension or anxiety before the theft, then feels relief or gratification
when committing the theft. The person may feel guilt afterward and often discard the objects after
stealing them, and also might have other compulsive disorders (such as an eating disorder or
obsessive compulsive disorder, OCD).

Whatever the underlying cause, if stealing is becoming a habit with your child or teen, consider
speaking with a doctor or therapist to get to the cause of the behavior. It's also important to routinely
monitoring your child's behavior, keep him or her away from situations in which stealing is a
temptation, and establish reasonable consequences for stealing if it does occur.

Reviewed by: W. Douglas Tynan, PhD, ABPP

Date reviewed: November 2011

Ages 6 to 9

As kids enter school, they're better able to understand the idea of consequences and that they can
choose good or bad behavior. It may help your child to imagine a stop sign that must be obeyed and
think about a situation before responding. Encourage your child to walk away from a frustrating
situation for a few minutes to cool off instead of having an outburst. Praise kids when they do walk
away and cool off — they're more likely to use those skills again.

When Kids Are Out of Control

As difficult as it may be, resist the urge to yell when you're disciplining your kids. Instead, be firm and
matter of fact. During a child's meltdown, stay calm and explain that yelling, throwing a tantrum, and
slamming doors are unacceptable behaviors that have consequences — and say what those
consequences are.

Your actions will show that tantrums won't get kids the upper hand. For example, if your child gets
upset in the grocery store after you've explained why you won't buy candy, don't give in — thus
demonstrating that the tantrum was both unacceptable and ineffective.

Also, consider speaking to your child's teachers about classroom settings and appropriate behavior
expectations. Ask if problem-solving is taught or demonstrated in school.

And model good self-control yourself. If you're in an irritating situation in front of your kids, tell them
why you're frustrated and then discuss potential solutions to the problem. For example, if you've
misplaced your keys, instead of getting upset, tell your kids the keys are missing and then search for
them together. If they don't turn up, take the next constructive step (like retracing your steps when
you last had the keys in-hand). Show that good emotional control and problem solving are the ways to
deal with a difficult situation.

If you continue to have difficulties, ask your doctor if family counseling sessions might help.
Discipline
Ages 6 to 8

Timeouts and consequences are also effective discipline strategies for this age group.

Again, consistency is crucial, as is follow-through. Make good on any promises of discipline or else you
risk undermining your authority. Kids have to believe that you mean what you say. This is not to say
you can't give second chances or allow a certain margin of error, but for the most part, you should act
on what you say.

Be careful not to make unrealistic threats of punishment ("Slam that door and you'll never watch TV
again!") in anger, since not following through could weaken all your threats. If you threaten to turn
the car around and go home if the squabbling in the backseat doesn't stop, make sure you do exactly
that. The credibility you'll gain with your kids is much more valuable than a lost beach day.

Huge punishments may take away your power as a parent. If you ground your son or daughter for a
month, your child may not feel motivated to change behaviors because everything has already been
taken away.

Ages 9 to 12

Kids in this age group — just as with all ages — can be disciplined with natural consequences. As they
mature and request more independence and responsibility, teaching them to deal with the
consequences of their behavior is an effective and appropriate method of discipline.

For example, if your fifth grader's homework isn't done before bedtime, should you make him or her
stay up to do it or even lend a hand yourself? Probably not — you'll miss an opportunity to teach a key
life lesson. If homework is incomplete, your child will go to school the next day without it and suffer
the resulting bad grade.
It's natural for parents to want to rescue kids from mistakes, but in the long run they do kids a favor
by letting them fail sometimes. Kids see what behaving improperly can mean and probably won't
make those mistakes again. However, if your child does not seem to be learning from natural
consequences, set up some of your own to help modify the behavior.

Am I 'Too Tough' When I Discipline My Kids?

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I've noticed that the more sternly I speak to my kids — for example, after they've run into the street
without looking — the more distraught they get. How can I make sure they understand the
seriousness of certain situations without making them feel worse?
- Zoe

As the saying goes, "Desperate times call for desperate measures." When your child's safety is at risk
— whether he's run into the street, reached for an open flame, or gotten dangerously close to a pool
— yelling, screaming, or crying out is a perfectly normal (and necessary!) response. After all, at that
moment, you would do anything possible to get your child's attention and get him out of harm's way.

After an episode like this, it's natural for kids to cry — and for you to want to apologize. But the truth
is, your kids are likely crying in response to the fear and urgency in your voice, not because you've
been "too stern." At times like these, it's OK to comfort them without apologizing. Give your child a
hug and say something like, "I know you're upset. But what you did was dangerous and I was scared
that you were going to get hurt. You must never do that again." Punishing kids after an event like this
is usually not necessary, since they've probably learned their lesson.

On the other hand, there are times when being too stern — like yelling regularly for minor offenses —
can backfire. Kids can become immune to parents' overblown reactions and fail to take them seriously.
If you feel yourself getting into this habit, take a deep breath before responding to your child's
behavior and ask yourself, "Am I about to overreact?" If so, walk away for a few minutes and come
back when you've calmed down.

In general, when it comes to disciplining kids, it's best to speak with a low, firm voice and to keep
your focus on the behavior, not the child. It's also helpful to use natural consequences whenever
possible. That means if your child has thrown a toy, ask her to pick it up. If she's taken something
from her sibling, ask her to return it. If she chooses not to comply, an age-appropriate timeout or
other consequence should follow, despite tearful pleas. Consistency is the key to effective discipline,
and giving in to a child's tears may inadvertently reinforce negative behavior.

Reviewed by: Elana Pearl Ben-Joseph, MD

Date reviewed: July 2013

 Nine Steps to More Effective Parenting

Raising kids is one of the toughest and most fulfilling jobs in the world — and the one for which you
might feel the least prepared.

Here are nine child-rearing tips that can help you feel more fulfilled as a parent — and enjoy your kids
more, too.

Nurture Your Child's Self-Esteem

Kids start developing their sense of self as babies when they see themselves through their parents'
eyes. Your tone of voice, your body language, and your every expression are absorbed by your kids.
Your words and actions as a parent affect their developing self-esteemmore than anything else.

Praising accomplishments, however small, will make them feel proud; letting kids do things
independently will make them feel capable and strong. By contrast, belittling comments or comparing
a child unfavorably with another will make kids feel worthless.

Avoid making loaded statements or using words as weapons. Comments like "What a stupid thing to
do!" or "You act more like a baby than your little brother!" cause damage just as physical blows do.

Choose your words carefully and be compassionate. Let your kids know that everyone makes mistakes
and that you still love them, even when you don't love their behavior.
Catch Kids Being Good

Have you ever stopped to think about how many times you react negatively to your kids in a given
day? You may find yourself criticizing far more often than complimenting. How would you feel about a
boss who treated you with that much negative guidance, even if it was well intentioned?

The more effective approach is to catch kids doing something right: "You made your bed without being
asked — that's terrific!" or "I was watching you play with your sister and you were very patient."
These statements will do more to encourage good behavior over the long run than repeated scoldings.

Make a point of finding something to praise every day. Be generous with rewards — your love, hugs,
and compliments can work wonders and are often reward enough. Soon you will find you are
"growing" more of the behavior you would like to see.

Set Limits and Be Consistent With Your Discipline

Discipline is necessary in every household. The goal of discipline is to help kids choose acceptable
behaviors and learn self-control. They may test the limits you establish for them, but they need those
limits to grow into responsible adults.

Establishing house rules helps kids understand your expectations and develop self-control. Some rules
might include: no TV untilhomework is done, and no hitting, name-calling, or hurtful teasing allowed.

You might want to have a system in place: one warning, followed by consequences such as a "time
out" or loss of privileges. A common mistake parents make is failure to follow through with the
consequences. You can't discipline kids for talking back one day and ignore it the next. Being
consistent teaches what you expect.

Make Time for Your Kids

It's often difficult for parents and kids to get together for a family meal, let alone spend quality time
together. But there is probably nothing kids would like more. Get up 10 minutes earlier in the morning
so you can eat breakfast with your child or leave the dishes in the sink and take a walk after dinner.
Kids who aren't getting the attention they want from their parents often act out or misbehave because
they're sure to be noticed that way.

Many parents find it rewarding to schedule together time with their kids. Create a "special night" each
week to be together and let your kids help decide how to spend the time. Look for other ways to
connect — put a note or something special in your kid's lunchbox.

Adolescents seem to need less undivided attention from their parents than younger kids. Because
there are fewer windows of opportunity for parents and teens to get together, parents should do their
best to be available when their teen does express a desire to talk or participate in family activities.
Attending concerts, games, and other events with your teen communicates caring and lets you get to
know more about your child and his or her friends in important ways.

Don't feel guilty if you're a working parent. It is the many little things you do — making popcorn,
playing cards, window shopping — that kids will remember.

Be a Good Role Model

Young kids learn a lot about how to act by watching their parents. The younger they are, the more
cues they take from you. Before you lash out or blow your top in front of your child, think about this:
is that how you want your child to behave when angry? Be aware that you're constantly being
observed by your kids. Studies have shown that children who hit usually have a role model for
aggression at home.

Model the traits you wish to cultivate in your kids: respect, friendliness, honesty, kindness, tolerance.
Exhibit unselfish behavior. Do things for other people without expecting a reward. Express thanks and
offer compliments. Above all, treat your kids the way you expect other people to treat you.

Make Communication a Priority

You can't expect kids to do everything simply because you, as a parent, "say so." They want and
deserve explanations as much as adults do. If we don't take time to explain, kids will begin to wonder
about our values and motives and whether they have any basis. Parents who reason with their kids
allow them to understand and learn in a nonjudgmental way.

Make your expectations clear. If there is a problem, describe it, express your feelings, and invite your
child to work on a solution with you. Be sure to include consequences. Make suggestions and offer
choices. Be open to your child's suggestions as well. Negotiate. Kids who participate in decisions are
more motivated to carry them out.

Be Flexible and Willing to Adjust Your Parenting Style

If you frequently feel "let down" by your child's behavior, perhaps you have unrealistic expectations.
Parents who think in "shoulds" (for example, "My kidshould be potty-trained by now") might find it
helpful to read up on the matter or to talk to other parents or child development specialists.

Kids' environments have an impact on their behavior, so you may be able to modify that behavior by
changing the environment. If you find yourself constantly saying "no" to your 2-year-old, look for
ways to restructure your surroundings so that fewer things are off-limits. This will cause less
frustration for both of you.

As your child changes, you'll gradually have to change your parenting style. Chances are, what works
with your child now won't work as well in a year or two.
Teens tend to look less to their parents and more to their peers for role models. But continue to
provide guidance, encouragement, and appropriate discipline while allowing your teen to earn more
independence. And seize every available moment to make a connection!

Show That Your Love Is Unconditional

As a parent, you're responsible for correcting and guiding your kids. But how you express your
corrective guidance makes all the difference in how a child receives it.

When you have to confront your child, avoid blaming, criticizing, or fault-finding, which undermine
self-esteem and can lead to resentment. Instead, strive to nurture and encourage, even when
disciplining your kids. Make sure they know that although you want and expect better next time, your
love is there no matter what.

Know Your Own Needs and Limitations as a Parent

Face it — you are an imperfect parent. You have strengths and weaknesses as a family leader.
Recognize your abilities — "I am loving and dedicated." Vow to work on your weaknesses — "I need to
be more consistent with discipline." Try to have realistic expectations for yourself, your spouse, and
your kids. You don't have to have all the answers — be forgiving of yourself.

And try to make parenting a manageable job. Focus on the areas that need the most attention rather
than trying to address everything all at once. Admit it when you're burned out. Take time out from
parenting to do things that will make you happy as a person (or as a couple).

Focusing on your needs does not make you selfish. It simply means you care about your own well-
being, which is another important value to model for your children.

Reviewed by: Steven Dowshen, MD

Date reviewed: June 2011
Understanding Violent Behavior In Children and Adolescents
There is a great concern about the incidence of violent behavior among children and adolescents. This
complex and troubling issue needs to be carefully understood by parents, teachers, and other adults.

Children as young as preschoolers can show violent behavior. Parents and other adults who witness the
behavior may be concerned, however, they often hope that the young child will "grow out of it." Violent
behavior in a child at any age always needs to be taken seriously. It should not be quickly dismissed as
"just a phase they're going through!"

Range of Violent Behavior

Violent behavior in children and adolescents can include a wide range of behaviors: explosive temper
tantrums, physical aggression, fighting, threats or attempts to hurt others (including homicidal thoughts),
use of weapons, cruelty toward animals, fire setting, intentional destruction of property and vandalism.

Factors Which Increase Risk of Violent Behavior

Numerous research studies have concluded that a complex interaction or combination of factors leads to
an increased risk of violent behavior in children and adolescents. These factors include:

 Previous aggressive or violent behavior

 Being the victim of physical abuse and/or sexual abuse
 Exposure to violence in the home and/or community
 Genetic (family heredity) factors
 Exposure to violence in media (TV, movies, etc.)
 Use of drugs and/or alcohol
 Presence of firearms in home
 Combination of stressful family socioeconomic factors (poverty, severe deprivation, marital
breakup, single parenting, unemployment, loss of support from extended family)
 Brain damage from head injury
What are the "warning signs" for violent behavior in children?
Children who have several risk factors and show the following behaviors should be carefully
evaluated:
 Intense anger
 Frequent loss of temper or blow-ups
 Extreme irritability
 Extreme impulsiveness
 Becoming easily frustrated
Parents and teachers should be careful not to minimize these behaviors in children.

What can be done if a child shows violent behavior?

Whenever a parent or other adult is concerned, they should immediately arrange for a comprehensive
evaluation by a qualified mental health professional. Early treatment by a professional can often help. The
goals of treatment typically focus on helping the child to: learn how to control his/her anger; express anger
and frustrations in appropriate ways; be responsible for his/her actions; and accept consequences. In
addition, family conflicts, school problems, and community issues must be addressed.

Can anything prevent violent behavior in children?

Research studies have shown that much violent behavior can be decreased or even prevented if the
above risk factors are significantly reduced or eliminated. Most importantly, efforts should be directed at
dramatically decreasing the exposure of children and adolescents to violence in the home, community,
and through the media. Clearly, violence leads to violence.

In addition, the following strategies can lessen or prevent violent behavior:

 Prevention of child abuse (use of programs such as parent training, family support programs,
etc.)
 Sex education and parenting programs for adolescents
 Early intervention programs for violent youngsters
 Monitoring child's viewing of violence on TV/videos/movies

 Raising Confident Kids

It takes confidence to be a kid. Whether going to a new school or stepping up to bat for the first time,
kids face a lot of uncharted territory.

Naturally, parents want to instill a can-do attitude in their kids so that they'll bravely take on new
challenges and, over time, believe in themselves. While each child is a little different, parents can
follow some general guidelines to build kids' confidence.

Self-confidence rises out of a sense of competence. In other words, kids develop confidence not
because parents tell them they're great, but because of their achievements, big and small. Sure, it's
good to hear encouraging words from mom and dad. But words of praise mean more when they refer
to a child's specific efforts or new abilities.
 When kids achieve something, whether it's brushing their own teeth or
riding a bike, they get a sense of themselves as able and capable, and tap into that high-octane fuel of
confidence.

Building self-confidence can begin very early. When babies learn to turn the pages of a book or
toddlers learn to walk, they are getting the idea "I can do it!" With each new skill and milestone, kids
can develop increasing confidence.

Parents can help by giving kids lots of opportunities to practice and master their skills, letting kids
make mistakes and being there to boost their spirits so they keep trying. Respond with interest and
excitement when kids show off a new skill, and reward them with praise when they achieve a goal or
make a good effort.

With plentiful opportunities, good instruction, and lots of patience from parents, kids can master basic
skills — like tying their shoes and making the bed. Then, when other important challenges present
themselves, kids can approach them knowing that they have already been successful in other areas.
Stay on the Sidelines

Of course, supervision is important to ensure that kids stay safe. But to help them really learn a new
skill, it's also important not to hover. Give kids the opportunity to try something new, make mistakes,
and learn from them.

For instance, if your son wants to learn how to make a peanut butter
sandwich, demonstrate, set up the ingredients, and let him give it a try. Will he make a bit of a mess?
Almost certainly. But don't swoop in the second some jelly hits the countertop. In fact, avoid any
criticism that could discourage him from trying again. If you step in to finish the sandwich, your son
will think, "Oh well, I guess I can't make sandwiches."

But if you have patience for the mess and the time it takes to learn, the payoff will be real. Someday
soon he'll be able to say, "I'm hungry for lunch, so I'm going to make my own sandwich." You might
even reply, "Great, can you make me one, too?" What a clear sign of your faith in his abilities!

Offer Encouragement and Praise

Sometimes, kids give up when frustrations arise. Help by encouraging persistence in the midst of
setbacks. By trying again, kids learn that obstacles can be overcome.

Once kids reach a goal, you'll want to praise not only the end result but also their willingness to stick
with it. For instance, after your son has mastered making that peanut butter sandwich you might show
your confidence by saying, "Next time, want to learn how to crack an egg?" Sandwich-fixing and egg-
cracking might not seem like huge achievements, but they're important steps in the right direction —
toward your child's independence.
Throughout childhood, parents have chances to prepare kids to take care of themselves. Sure, it's
great to feel needed, but as kids steadily gain confidence and independence, their relationship with
you can be even richer. You can be bonded, not just by dependence, but by love and shared pride in
all they've achieved.

Eventually, your grown-up kids just might say thanks for how prepared they feel for the road ahead —
a road they can take with confidence.

Reviewed by: D'Arcy Lyness, PhD

Date reviewed: July 2013